Health Net, Inc. is a publicly traded managed care organization that delivers managed health care services through health plans and government-sponsored managed care plans. Its mission is to help people be healthy, secure and comfortable. Health Net, through its subsidiaries, provides and administers health benefits to approximately 5.4 million individuals across the country through group, individual, Medicare (including the Medicare prescription drug benefit commonly referred to as "Part D"), Medicaid, U.S. Department of Defense, including TRICARE, and Veterans Affairs programs. Health Net's behavioral health services subsidiary, Managed Health Network, Inc., provides behavioral health, substance abuse and employee assistance programs to approximately 4.9 million individuals, including Health Net's own health plan members. Health Net's subsidiaries also offer managed health care products related to prescription drugs, and offer managed health care product coordination for multi-region employers and administrative services for medical groups and self-funded benefits programs.
For more information on Health Net, Inc., please visit the company's website at
The Medical Director, Central Medical Management, works to actively ensure that centralized medical management activities result in cost effective, quality-oriented health care consistent with the member's health care benefit package and designed to provide the member the best possible clinical outcomes. Centralized medical management activities consist of such functions as prior authorization, appeals and grievances, case management, and retrospective review.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Leads the effective operational management of assigned departments or functions with an emphasis on execution, outcomes, continual improvement and performance enhancement.
- Participates in quality improvement programs to assure that members receive timely, appropriate, and accessible health care.
- Provides ongoing compliance with standardized Health Net, Inc. systems, policies, programs, procedures, and workflows.
- Participates and supports communication, education, and maintenance of partnerships with contracted providers, provider physician groups and IPA's and may serve as the interface between Plan and providers.
- Responsible for recommending changes and enhancements to current managed care, prior authorization, concurrent review, case management and disability review guidelines and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods and treatment protocols.
- May participate in business development, program development, and development of care integration models for increased care delivery efficiency and effectiveness.
- Participates in the administration of medical management programs to ensure that providers deliver and Plan members receive appropriate, high quality, cost effective care.
- Articulates Plan policies and procedures to providers and organizations and works to ensure effective implementation of policies and programs.
- Analyzes population-based reports to refine management activities, investigate and define variation, and ensure conformance to expected standards and targets.
- Investigates selected cases reported as deviating from accepted standards and takes appropriate actions.
- Actively interfaces with providers to improve health care outcomes, health care service utilization and costs.
- Analyzes member and population data to guide and manage program direction such as ensuring that members enroll in clinical programs indicated by their clinical need.
- Optimizes utilization of medical resources to maximize benefits for the member while supporting Health Net Plans and Health Net corporate initiatives.
- Assists in the analysis of performance data of physicians and hospitals and the development and implementation of a corrective action plan.
- Supports state regulatory relationships and may serve as the lead physician for state and federal medical management regulatory audits (i.e., NCQA, HEDIS, URAC).
- Actively supports Quality and Compliance to ensure that Health Net meets or exceeds medical management, regulatory, agency, and quality standards.
Graduate of an accredited medical school; Doctorate degree in medicine or osteopathy
Board certification in an ABMS recognized specialty
Unrestricted California Medical License
Knowledge, Skills & Abilities:
- Minimum five years medical practice after completing residency-training requirements for board eligibility.
- Minimum three years medical management experience in a managed care environment.
- Experience with Medi-Cal program and/or Medi-Cal patients preferred
The following section describes the general physical requirements for this position. Please note that 'constant' refers to more than 81% of time; 'significant' refers to 40-80%;and 'moderate' refers to 20-40% of the time.
- Demonstrated excellent interpersonal skills.
xcellent oral and written communications skills.
- Current knowledge of industry standard medical management tools.
- Strong analytical and problem solving skills.
- Ability to work independently.
- Ability to set priorities and achieve objectives.
- Strong organizational skills.
- Must be able to work well with all levels in the organization, and participate as a member of a national medical management leadership team.
- Ability to operate PC-based software programs including proficiency in Word, Excel, PowerPoint, Access and MS Project.
- Some local area or in-state travel may be required from time to time.
- Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.
- Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.
- May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays).
- May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.
- Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.
- Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.
- Required to have hearing ability to receive detailed information through oral communication.
- Required to have speaking ability to express or exchange ideas.
- Constant computer usage including constant typing and/or eye strain.
- Significant repetitive arm, wrist, hand and finger motions -- making repetitive movements (e.g. key boarding, filing, data entry).
- Moderate phone usage; headsets may be required.
- Moderate travel may be required between work sites and/or out of area.
- Moderate work in a loud office environment with frequent interruptions/distractions.
- Constant sedentary work (desk bound or seated).
- Constant reading is required via computer screen and/or bound printed materials.
- Constant concentration may be required on various subjects by listening, reading and thinking clearly.
- Constant interaction with others may be required.
May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required.
This may require face-to-face or telephone interactions.
- Constant thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one or several things to the next.
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.
Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.
Health Net - 10 months ago